Havering Energy Doctors - Referral Form

Title

First Name

Surname

Telephone Number

Email

House/Flat Number

Street Name

Town

Post Code

Date of Birth (DD/MM/YYYY)

Gender

Ethnicity

Health Conditions (please state)

On average, how would you describe your home throughout the winter: Very Cold Cold Quite Cold Quite Warm Warm Very Warm

Do you have difficulties paying your energy bills? Yes No

Would you like a Benefit Check? Yes No

I agree for my details to be passed on to Age UK East London to carry out the Home Energy Check Yes No